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PubMed2004

Early and long-term outcome of elective stenting of the infarct-related artery in patients with viability in the infarct-area: Rationale and design of the Viability-guided Angioplasty after acute Myocardial Infarction-trial (The VIAMI-trial).

BACKGROUND: Although percutaneous coronary intervention (PCI) is becoming the standard therapy in ST-segment elevation myocardial infarction (STEMI), to date most patients, even in developed countries, are reperfused with intravenous thrombolysis or do not receive a reperfusion therapy at all. In the post-lysis period these patients are at high risk for recurrent ischemic events. Early identification of these patients is mandatory as this subgroup could possibly benefit from an angioplasty of the infarct-related artery.Since viability seems to be related to ischemic adverse events, we initiated a clinical trial to investigate the benefits of PCI with stenting of the infarct-related artery in patients with viability detected early after acute myocardial infarction. METHODS: The VIAMI-study is designed as a prospective, multicenter, randomized, controlled clinical trial. Patients who are hospitalized with an acute myocardial infarction and who did not have primary or rescue PCI, undergo viability testing by low-dose dobutamine echocardiography (LDDE) within 3 days of admission. Consequently, patients with demonstrated viability are randomized to an invasive or conservative strategy. In the invasive strategy patients undergo coronary angiography with the intention to perform PCI with stenting of the infarct-related coronary artery and concomitant use of abciximab. In the conservative group an ischemia-guided approach is adopted (standard optimal care).The primary end point is the composite of death from any cause, reinfarction and unstable angina during a follow-up period of three years. CONCLUSION: The primary objective of the VIAMI-trial is to demonstrate that angioplasty of the infarct-related coronary artery with stenting and concomitant use of abciximab results in a clinically important risk reduction of future cardiac events in patients with viability in the infarct-area, detected early after myocardial infarction.

Journal Article↗
PubMed2005

Serial changes in plasma brain natriuretic peptide concentration at the infarct and non-infarct sites in patients with left ventricular remodelling after myocardial infarction.

OBJECTIVES: To clarify the role of infarct and non-infarct sites on left ventricular (LV) remodelling after myocardial infarction by measuring brain natriuretic peptide (BNP) from each site. METHODS AND RESULTS: BNP from the aorta and the anterior interventricular vein (AIV) was measured in 45 patients with first anterior myocardial infarction at one, six, and 18 months. The LV was significantly dilated (> 10 ml/m(2) of end diastolic volume from one to 18 months) in 20 patients (remodelling (R) group) but not in 25 others (non-remodelling (NR) group). Patient characteristics and LV functions did not differ significantly at one month but plasma BNP concentration was higher in group R than in group NR (336 (288) v 116 (106) pg/ml, p < 0.01), predicting the degree of LV dilatation. The difference in BNP concentration between the aortic root and AIV (DeltaBNP), reflecting BNP secreted from the infarct site, did not differ at one month. In both groups BNP and DeltaBNP significantly decreased from one to six months (p < 0.05) and decreased from six months to 18 months, but the change was not significant. BNP and DeltaBNP were significantly higher in group R than in group NR after six months, when LV dilatation was not evident in both groups. CONCLUSION: Enhanced BNP secretion at one month in the non-infarct and infarct ventricular sites predicts subsequent LV dilatation (that is, remodelling). The slower process of LV remodelling decreased BNP secretion at both sites. Thus, BNP concentration should be useful for monitoring ventricular remodelling after infarction.

Cardiomyopathy, Dilated↗
PubMed2004

Abciximab-supported infarct artery stent implantation for acute myocardial infarction and long-term survival: a prospective, multicenter, randomized trial comparing infarct artery stenting plus abciximab with stenting alone.

BACKGROUND: The impact on survival of routine use of abciximab as adjunctive treatment to routine infarct artery stenting for acute myocardial infarction is not defined. We sought to determine the effect of abciximab on 1-year survival and other major adverse cardiac events of patients with acute myocardial infarction undergoing routine infarct artery stenting. METHODS AND RESULTS: The Abciximab and Carbostent Evaluation (ACE) Trial is an unblinded, randomized, controlled trial that compared abciximab with placebo in patients undergoing routine infarct artery stent implantation for acute myocardial infarction. At 1 year, the survival rate was 95+/-2% in the abciximab group and 88+/-2% in the stent-alone group (P=0.017). The reinfarction rate was 1% in the abciximab group and 6.0% in the stent-alone group, whereas there were no differences between groups in target vessel revascularization rate (16.5% in the abciximab group, 17.5% in the stent-alone group). CONCLUSIONS: Abciximab as adjunctive treatment to routine infarct artery stenting for acute myocardial infarction resulted in improved 1-year survival and lower reinfarction rates.

Abciximab↗
PubMed1992

Selective inhibition of the contractile apparatus. A new approach to modification of infarct size, infarct composition, and infarct geometry during coronary artery occlusion and reperfusion.

BACKGROUND: Myocardial reperfusion is associated with calcium overload and cell contracture, mechanisms that may precipitate cell death. In this study, we tested the hypothesis that in vivo inhibition of this contracture could lead to cell preservation in an open-chest large animal model. METHODS AND RESULTS: Regional myocardium function was measured during a selective intracoronary infusion of 2,3-butanedione monoxime (BDM), a specific inhibitor of actin-myosin coupling, in the control state (10 pigs) and in a protocol of a 51-minute coronary occlusion followed by reperfusion (40 pigs). The effects on coronary artery blood flow in the basal state were also studied (seven pigs). Intramyocardial distribution of the infusate during coronary occlusion, myocardial water content after 30 minutes of reperfusion and area at risk, infarct size, type of histological necrosis, and infarct geometry after 24 hours of reperfusion were assessed. Methods used included electromagnetic flowmeter, radiolabeled microspheres, subendocardial sonomicrometers, fluorescein, triphenyl tetrazolium chloride and Masson's trichrome staining, and computer quantification of infarct edges. In the absence of ischemia, BDM infusion inhibited regional shortening in a dose-dependent manner up to full systolic bulging while producing marked regional increase in coronary blood flow. During early reperfusion, BDM reduced end-diastolic length 76% more than the control infusion (p less than 0.05) and increased systolic bulging by 420% compared with no change in control animals. The ratio of infarct size/area at risk was reduced by 31% with BDM (p less than 0.05), with striking modifications of infarct histology and infarct geometry; specifically, the extent of contraction band necrosis was reduced by 63% from 105.5 +/- 18.2 to 39.2 +/- 13.6 mm2 (p less than 0.02), and more patches of necrosis (6.5 +/- 2.1 versus 1.6 +/- 0.4, p less than 0.05) and higher contour (7.7 +/- 1.2 versus 5.03 +/- 0.2, p less than 0.05) and fractal (12.1 +/- 1.3 versus 7.8 +/- 0.2, p less than 0.05) indexes were found. CONCLUSIONS: Selective intracoronary infusion of BDM at doses inhibiting regional wall motion decreased infarct size after reperfusion. The effects of BDM on regional function, the reduction in contraction band necrosis at histology, and the peculiar configuration of these infarcts all suggest that inhibition of contracture can interfere with cell-to-cell progression of myocardial necrosis, supporting a role for contracture in reperfusion-induced cell death.

Actins↗
PubMed1992

[Early diagnosis of the site of infarction and the infarct-related coronary artery in patients with acute inferior myocardial infarction].

We evaluated the site and infarct-related arteries from electrocardiograms (ECGs) recorded early after the onset in cases of inferior infarction (IMI). The subjects were 80 patients with IMI admitted within 6 hours from the onset. We analyzed the ECGs on admission, at 24 hours, at 4 weeks. All patients underwent ventriculography and coronary angiography at 4-6 weeks from the onset. Regional wall motion and ejection fraction (FF) were measured. The infarct-related artery was decided on by the site of the asynergy. Patients were allocated into 2 groups according to the infarct-related artery; ie right (RCA, n = 52) and left circumflex (LCX, n = 52). Parameters measured were leads showing ST elevation (ST increases), width of R waves and R/S ratio in V1,2. Amplitude of U waves in V1-3. We defined U greater than or equal to 0.5mm as abnormal (GU). A significantly greater number of patients with GU showed asynergy in posterolateral and posterobasal segments compared to those without GU. The EF was significantly lower in patients with GU. As to the infarct-related arteries, a significantly greater number of patients with LCX disease showed concomitant posterior infarction (PMI) than those with RCA disease. Also a significantly greater number of those with LCX disease showed GU and ST increases in V5,6 than those with RCA disease. Therefore, we conclude that GU in V1-3 is a new marker suggesting posterolateral and posterobasal damage, and GU in V1-3, ST increases in V5,6 and electrocardiographic PMI are specific markers for the diagnosis of LCX related infarction.

Adult↗
PubMed1989

[Success and complication rates of coronary angioplasty in the unstable angina pectoris stage after myocardial infarct--a comparison with percutaneous transluminal coronary angioplasty in the acute infarct stage and unstable angina pectoris without preceding myocardial infarct].

To evaluate whether there is a difference in terms of the success and complication rates of PTCA in patients (pts) with unstable angina pectoris (UAP) after myocardial infarction (group I) and patients with myocardial infarction (group II), as well as in patients with UAP without preceding myocardial infarction (group III), we analyzed the data of 188 patients retrospectively. Acute PTCA was performed in 42 patients of group I, 55 patients of group II, and 91 patients of group III. The primary success rate was comparable in all three groups (group I: 74%; group II: 76%; group III: 77%). The incidence of acute ACVB operation was comparable in group I (5 pts: 9%) and group III (10 pts: 11%). One patient was operated during an acute myocardial infarction. Five patients of group I (9%) and seven patients of group III (8%) developed a myocardial infarction. Three patients of group I (7%) and three patients of group II (5%) died during hospitalization. PTCA performed during acute myocardial ischemia has the highest complication rate in patients with UAP after myocardial infarction and is considerably higher than in patients with UAP without preceding infarction.

Angina Pectoris↗
PubMed2001

Differences in treatment and outcome of patients with acute myocardial infarction admitted to hospitals with compared to without departments of cardiology; results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA 1+2) Registries and the Myocardial Infarction Registry (MIR).

AIMS: The specialty of the admitting physician may influence treatment and outcome in patients with acute myocardial infarction. METHODS AND RESULTS: The pooled data of three German acute myocardial infarction registries: the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) 1+2 studies and the Myocardial Infarction Registry (MIR) were analysed. Patients admitted to hospitals with departments of cardiology were compared to hospitals without such departments. A total of 24 814 acute myocardial infarction patients were included, 9020 (36%) patients at 91 (29.8%) hospitals with departments of cardiology and 15 794 (64%) at 214 (70.2%) hospitals without cardiology departments. There were only minor differences in patient characteristics and prevalence of concomitant diseases between the two types of hospital. The first electrocardiogram was more often diagnostic at hospitals with cardiology departments (71.8% vs 66.5%, P<0.001). Reperfusion therapy and adjunctive medical therapy, such as aspirin, beta-blockers and ACE-inhibitors were used more often at cardiology departments (all P -values <0.001), even after adjustment for confounding parameters. Treatment improved at both types of hospital over time. Admission to a hospital with a department of cardiology was independently associated with a lower hospital mortality (14.2% vs 15.4%, adjusted OR=0.91; 95%CI: 0.83-0.99). Additional logistic regression models showed that the higher use of reperfusion therapy and recommended concomitant medical therapy was responsible for most of the survival benefit at such hospitals. CONCLUSION: Treatment of acute myocardial infarction patients at hospitals with departments of cardiology was independently associated with a higher use of recommended therapy and a lower hospital mortality compared to hospitals without such departments.

Aged↗
PubMed2000

Transfer of patients with acute myocardial infarction for primary or acute angioplasty from hospitals without the facilities to perform angioplasty. Results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) Registry and the Myocardial Infarction Registry (MIR).

In patients with acute myocardial infarction (AMI) admitted at hospitals without angioplasty facilities there are some subgroups of patients which seem to profit from a transfer to primary or acute angioplasty. However, current clinical practice at such hospitals is unknown. We analyzed the pooled data of the German acute myocardial infarction registries MITRA and the MIR. Angioplasty was not available at 221/271 hospitals (81.5%). Out of 14,487 patients with acute myocardial infarction admitted to these hospitals, 50.1% (7,259/14,487) received thrombolysis at the initial hospital and 3.6% (523/14,487) were transferred. Out of the transferred patients, 55.3% (289/523) were treated with primary angioplasty and 44.7% (234/523) received a combination of thrombolysis and angioplasty. The proportion of transferred patients increased from 1.1% in 1994 to 5.5% in 1998 (p for trend = 0.001). One hundred and four hospitals (47.1%) never transferred patients. Patients transferred for primary angioplasty (289 patients) were compared to patients treated with thrombolysis at the initial hospitals (7,259 patients). Multivariate analysis showed the following independent predictors for transfer of patients for primary angioplasty: contraindications for thrombolysis (OR = 17.9), a non-diagnostic first ECG (OR = 4.0), pre-hospital delay > 6 hours (OR = 2.5), unknown symptom onset of the acute myocardial infarction (OR = 2.0) and anterior wall acute myocardial infarction (OR = 1.6). Heart failure at admission was the only independent predictor not to transfer patients (OR = 0.40). In Germany only 47.1% of hospitals without angioplasty facilities transfer patients with acute myocardial infarction to primary or acute angioplasty. The proportion of transferred patients increased from 1.1% in 1994 to 5.5% in 1998. Contraindications for thrombolysis were the strongest predictor to transfer patients to primary angioplasty.

Aged↗
PubMed1994

Effects of late percutaneous transluminal coronary angioplasty of an occluded infarct-related coronary artery on left ventricular function in patients with a recent (< 6 weeks) Q-wave acute myocardial infarction (Total Occlusion Post-Myocardial Infarction Intervention Study [TOMIIS]--a pilot study).

The effect of late percutaneous transluminal coronary angioplasty (PTCA) of an occluded infarct-related artery on left ventricular ejection fraction was studied in patients with a recent, first Q-wave myocardial infarction in a prospective, randomized study. Forty-four patients (31 men and 13 women, mean age 58 +/- 12 years) with an occluded infarct-related coronary artery were randomized to PTCA (n = 25) or no PTCA (n = 19). Patients received acetylsalicylic acid, a beta blocker and an angiotensin-converting enzyme inhibitor unless contraindicated. Left ventricular ejection fraction was determined at baseline and 4 months. Coronary angiography was repeated at 4 months. Baseline ejection fraction measured 20 +/- 12 days after myocardial infarction was 45 +/- 12% in both groups. PTCA was performed 21 +/- 13 days after the event. The primary PTCA success rate was 72%. One patient in each group died before angiographic follow-up, which was completed in 37 of the remaining 42 patients (88%; 21 with and 16 without PTCA). At 4 months, the infarct-related artery was patent in 43% of PTCA patients and in 19% of no PTCA patients (p = NS). Reocclusion occurred in 40% of patients after successful PTCA. Secondary analyses showed that the change in left ventricular ejection fraction was significantly greater in patients with a patent infarct-related artery (+9.4 +/- 6.2%) than in those with an occluded artery (+1.6 +/- 8.8%; p = 0.0096). Baseline ejection fraction also independently predicted improvement in left ventricular ejection fraction (p = 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed2005

Relationship between residual blood flow in the infarct-related artery and scintigraphic infarct size, myocardial salvage, and functional recovery in patients with acute myocardial infarction.

UNLABELLED: In patients with acute myocardial infarction (AMI) before primary coronary stenting with adjunct glycoprotein IIb/IIIa receptor blockade, whether residual blood flow in the infarct-related artery (IRA) affects infarct size or myocardial salvage is not known. METHODS: This study included 118 patients with ST-segment elevation AMI who received coronary stenting plus abciximab. SPECT studies were performed before and 7-14 d after stenting. RESULTS: Patients were divided into a group with initial Thrombolysis in Myocardial Infarction (TIMI) flow grade < or = 1 (77 patients) and a group with initial TIMI flow grade > 1 (41 patients). The initial median perfusion defect and (in brackets) the 25th and 75th percentiles were 29.1% [21.0%; 52.0%] of the left ventricle in patients with TIMI flow grade < or = 1, versus 16.5% [8.0%; 33.1%] of the left ventricle in patients with TIMI flow grade > 1 (P < 0.001). Baseline left ventricular ejection fraction (54.0% [45.0; 63.0] vs. 57.0% [40.0; 62.0], P = 0.623) or extension of hypokinetic region (28.0 [14.0; 41.0] hypokinetic chords vs. 24.0 [13.0; 39.0] hypokinetic chords, P = 0.643) did not differ significantly between the group with TIMI flow grade < or = 1 and the group with TIMI flow grade > 1. Final infarct size was 11.0% [6.1%; 23.5%] of the left ventricle in the group with TIMI flow grade < = 1, versus 6.0% [2.0%; 12.8%] of the left ventricle in the group with TIMI flow > 1 (P = 0.008). Salvage index was 0.58 [0.38; 0.76] in the group with TIMI flow grade < or = 1, versus 0.61 [0.36; 0.74] in the group with TIMI flow grade > 1 (P = 0.952). At the day 14 angiography, patients with TIMI flow grade > 1 had better left ventricular ejection fraction (61.0% [54.0%; 68.0%] vs. 56.5% [42.9%; 65.0%]; P = 0.03) and a smaller hypokinetic region (7 chords [0; 22.0] vs. 16 chords [2.5; 30.0]; P = 0.024) than did patients with TIMI flow grade < or = 1. CONCLUSION: Preserved blood flow in the IRA in patients with AMI is associated with a smaller area at risk, a smaller infarct, and better recovery of regional and global left ventricular function. The proportion of initial area at risk salvaged by coronary stenting does not seem to depend on residual blood flow in the IRA.

Aged↗
PubMed1990

[Risk factors in atherothrombotic cerebral infarct. Are there differential risk profiles in extensive cortical infarct and lacunar infarct? A case-control study].

A study of cases and controls was performed to define the factors associated with nonembolic cerebral infarction and to compare the risk profiles of extensive cortical infarction (ECI) to those of lacunar infarction (LI). One hundred and four patients with ECI were matched with 71 patients with LI and with 90 controls. Although the initial analysis disclosed multiple factors associated with cerebral infarction, the analysis with control of the factors revealed that the only factors related with the occurrence of atherothrombotic infarction were: arterial hypertension [odds ratio (OR) = 6.8], diabetes mellitus (OR = 5.6), ischemic cardiac disease (OR = 5.5), increased hematocrit value (OR = 3.0), and atherogenic lipids in patients without arterial hypertension nor diabetes. Diabetes appeared as the only factor specifically associated with LI when compared with ECI (OR = 2.1). This study supports the following conclusions: 1) the risk profile of nonembolic cerebral infarction is concise and intelligible, 2) the possible role of arterial hypertension in the genesis of LI was not confirmed, and 3) diabetic microangiopathy may be implicated in the genesis of most of LI. Conclusions from this retrospective study should be taken as an interpretation of the results since some restriction in the sensitivity of the data analysis was deliberately introduced.

Aged↗
PubMed2001

Double-blind, randomized trial of an anti-CD18 antibody in conjunction with recombinant tissue plasminogen activator for acute myocardial infarction: limitation of myocardial infarction following thrombolysis in acute myocardial infarction (LIMIT AMI) study.

BACKGROUND: Inhibition of leukocyte adhesion can reduce myocardial infarct size in animals. This study was designed to define the safety and efficacy of a recombinant, humanized, monoclonal antibody to the CD18 subunit of the beta2 integrin adhesion receptors (rhuMAb CD18), in reducing infarct size in patients treated with a thrombolytic agent. METHODS AND RESULTS: The Limitation of Myocardial Infarction following Thrombolysis in Acute Myocardial Infarction Study (LIMIT AMI) was a randomized, double-blind, placebo-controlled, multicenter study conducted in 60 centers in the United States and Canada. A total of 394 subjects who presented within 12 hours of symptom onset with ECG findings (ST-segment elevation) consistent with AMI were treated with recombinant tissue plasminogen activator and were also given an intravenous bolus of 0.5 or 2.0 mg/kg rhuMAb CD18 or placebo. Coronary angiography was performed at 90 minutes, 12-lead ECGs were obtained at baseline, 90, and 180 minutes, and resting sestamibi scans were performed at >/=120 hours. Adjunctive angioplasty and use of glycoprotein IIb/IIIa antiplatelet agents at the time of angiography were discretionary. There were no treatment effects on coronary blood flow, infarct size, or the rate of ECG ST-segment elevation resolution, despite the expected induction of peripheral leukocytosis. A slight trend toward an increase in bacterial infections was observed with rhuMAb CD18 (P=0.33). CONCLUSIONS: RhuMAb CD18 was well tolerated but not effective in modifying cardiac end points.

Antibodies, Monoclonal↗
PubMed2006

Application of the Thrombolysis in Myocardial Infarction risk index in non-ST-segment elevation myocardial infarction: evaluation of patients in the National Registry of Myocardial Infarction.

OBJECTIVES: The purpose of this research was to evaluate the Thrombolysis In Myocardial Infarction risk index (TRI) to characterize the risk of death among patients with non-ST-segment elevation myocardial infarction (NSTEMI). BACKGROUND: The TRI, calculated from baseline age, systolic pressure, and heart rate, was established in patients with ST-segment elevation myocardial infarction (STEMI) and is predictive of mortality. Patients presenting with NSTEMI are increasing compared to STEMI and constitute a group with varied risk. METHODS: The TRI was calculated in 337,192 patients from the National Registry of Myocardial Infarction with NSTEMI. Values and outcomes were compared with 153,486 patients with STEMI classified by reperfusion status. Comparisons of baseline characteristics and clinical outcomes stratified by TRI were made. RESULTS: There was a graded relationship between the TRI and mortality in patients with NSTEMI with a >30-fold difference in mortality rates between lowest and highest deciles (p < 0.0001). The index showed good discrimination (c = 0.73). Overall mortality in the group with NSTEMI was higher (10.9%) than patients with STEMI treated with (6.6%) but lower than for STEMI patients not receiving reperfusion therapy (18.7%). The higher risk in comparison to patients with STEMI treated with reperfusion therapy was explained largely by the higher-risk profile of the population with NSTEMI. CONCLUSIONS: There is a graded relationship between TRI and mortality in patients with NSTEMI. This simple risk index provides important information about mortality in patients across the spectrum of myocardial infarction, STEMI and NSTEMI. Early identification of NSTEMI patients who are at high risk of in-hospital mortality may provide clinicians with important information for initial triage and treatment.

Aged↗
PubMed1996

[Perioperative myocardial infarction and cardiac complications after noncardiac surgery in patients with prior myocardial infarction. III: Troponin T--a significant diagnostic alternative in perioperative myocardial infarction?].

UNLABELLED: Diagnosis of a perioperative myocardial infarction (PMI) on the basis of measurement of the creatine kinase MB fraction (CKMB) alone is not always easy. Surgical traumatisation of muscle fibres can lead to false-positive elevations. Newly introduced laboratory tests for cardiac troponins seem to facilitate the diagnosis of PMI. We measured serum values of cardiac troponin T in 139 patients described in detail in part I and compared them with common diagnostic tools for myocardial infarction. METHODS: In all, 139 patients were enrolled (part I). Clotted serum samples were taken preoperatively and daily until day 3, centrifuged, and stored at -20 degrees C until analysis. Our Department of Clinical Biochemistry and Haematology used a commercially available sandwich immunoassay (Troponin T ELISA, Boehringer, Mannheim, Germany). The measurements of CK and CKMB were performed with an automated analyser (CK, CK-MB, Boehringer, Mannheim, Germany). Serum values of troponin T were defined according to company recommendations: detection level: 0.04 ng/ml, threshold value for myocardial ischaemia: > or = 0.2 ng/ml, value for diagnosis of non-Q-wave infarction: > or = 1.0 ng/ml, and value for diagnosis of Q-wave infarction: > or = 3.0 ng/ml. We therefore assumed a value of > or = 1.0 ng/ml troponin T as being positive for MI, comparable with a CKMB value > or = 6% of total CK (part I). Statistical analysis was the same as described in part I. RESULTS: Six of the 139 patients had a perioperative infarction, 3 of them had CKMB levels > or = 6%, 3 had an elevation of troponin T > or = 1.0 ng/ml. The sensitivity was 50% for both troponin T and CKMB. Values for specificity were 98% for troponin T and 95% for CKMB. Two of 8 patients with troponin T levels > or = 0.2 ng/ml preoperatively had a reinfarction (Table 5). Three of 8 patients with preoperative elevations of cardiac troponin T > or = 0.2 ng/ml versus 4 of 131 others had left ventricular failure postoperatively (P < 0.05). On day 3 significantly more patients with pathological levels of troponin T had left ventricular failure (5 of 12 vs. 0 of 127, P < 0.05). Patients with pathological depression of the ST segment on Holter ECG more often had elevations of troponin T values on day 3 than patients without (3 of 25 vs. 4 of 75, P = 0.048). There was an unexplained coincidence of elevated preoperative serum creatinine levels > 120 mumol/l and troponin T values (Table 6). CONCLUSION: Troponin T is a highly specific marker for perioperative myocardial cell necrosis. Patients with raised levels preoperatively seem to be at higher risk for postoperative reinfarction and left ventricular failure. The prognostic value of such an elevation is not clearly defined, especially in patients with chronic renal failure.

Aged↗
PubMed1989

Risk stratification in patients with first non-Q wave infarction: limited value of the early low level exercise test after uncomplicated infarcts. The Multicenter Post-Infarction Research Group.

Risk stratification using clinical and historical variables plus early low level exercise testing was performed in 141 patients with a first non-Q wave myocardial infarction. The 111 patients who performed the exercise test had a 3.6% cardiac mortality rate in the first year compared with 13.3% in the 30 patients who could not exercise (p = 0.063), and a 1 year incidence rate of recurrent cardiac events (cardiac death or recurrent nonfatal myocardial infarction) of 10.8% compared with 23.3% (p = 0.127). Patients who developed ischemia (ST depression or angina) during the test had an increased incidence of cardiac events in the year after the infarction (odds ratio greater than 3, p less than 0.05). When patients were subgrouped by the presence or absence of pulmonary congestion, the discriminatory value of the exercise test was seen to reside primarily in the cohort with pulmonary congestion. For example, ST depression during exercise in this group identified patients with a 71% incidence of cardiac events in the year after the infarction compared with 5.3% for those without ST depression (odds ratio 45, p = 0.002). In the patients without pulmonary congestion, the exercise test had no discriminatory value. It is concluded that early low level exercise testing has a limited role after an uncomplicated non-Q wave infarction, but is useful in patients with clinical markers of higher risk.

Electrocardiography↗
PubMed1996

Distortion of the terminal portion of the QRS on the admission electrocardiogram in acute myocardial infarction and correlation with infarct size and long-term prognosis (Thrombolysis in Myocardial Infarction 4 Trial).

Previous studies have shown an association between distortion of the terminal portion of the QRS (QRS[+] pattern: emergence of the J point > or = 50%. of the R wave in leads with qR configuration or disappearance of the S wave in leads with an Rs configuration) on admission and in-hospital mortality in acute myocardial infarction (AMI). However, the mechanism for this association is not known. We assessed the relation between QRS(+) pattern and coronary angiographic findings, infarct size, and long-term prognosis in the Thrombolysis In Myocardial Infarction 4 trial. Patients were allocated into 2 groups based on the presence (QRS[+], n = 85) or absence (QRS[-], n = 293) of QRS distortion. The QRS(+) patients were older (mean +/- SD: 61.1 +/- 10.6 vs 57.5 +/- 10.6 years, p = 0.004), had more anterior AMI (49% vs 37%, p = 0.04), and less previous angina (42% vs 54%, p = 0.05). QRS(+) patients had larger infarct size as assessed by creatine kinase release over 24 hours (209 +/- 147 vs 155 +/- 129, p = 0.003), and predischarge sestamibi (MIBI) defect (17.9 +/- 15.9% vs 11.2 +/- 13.4%, p <0.001). When adjusting for difference in baseline characteristics, p values for the differences in 24-hour creatine kinase release were 0.03 and 0.64 for anterior and nonanterior AMI, respectively, and for MIBI defect size 0.03 and 0.02, respectively. One-year mortality (18% vs 6%, p = 0.03) was higher and the weighted end point of death, reinfarction, heart failure, or left ventricular ejection fraction <40% (0.33 +/- 0.37 vs 0.24 +/- 0.32, p = 0. 13), tended to be higher in the anterior AMI patients with QRS(+). No difference in clinical outcome was found in patients with non-anterior AMI. These findings suggest that this simple electrocardiographic definition of presence of QRS(+) pattern on admission may provide an early estimation of infarct size and long-term prognosis, especially in anterior AMI.

Adult↗
PubMed1999

Early use of ACE inhibitors in the treatment of acute myocardial infarction in the United States: experience from the National Registry of Myocardial Infarction 2. National Registry of Myocardial Infarction 2 participants.

This study was undertaken to examine recent trends in the use of angiotensin-converting enzyme (ACE) inhibitors within 24 hours of admission in patients hospitalized for acute myocardial infarction (AMI) and to identify clinical factors associated with ACE inhibitor-prescribing patterns. Demographic, procedural, and acute medication use from 202,438 patients with AMI were collected at 1,470 US hospitals participating in the National Registry of Myocardial Infarction 2 from June 1994 through June 1996. Acute ACE inhibitor use increased from 14.0% in 1994 to 17.3% in 1996. After controlling for all important clinical variables, we found that there was a significant increase in the odds of acute ACE inhibitor treatment over time (odds ratio [OR]1.07 for each 180-day period; 95% confidence intervals [CI] 1.06 to 1.08; p<0.0001). Univariate data suggested that patients treated acutely with ACE inhibitors tended to be older (70.9 vs. 67.2 years) and had lower rates of in-hospital mortality (8.8% vs. 11.0%). Independent predictors of receiving an ACE inhibitor acutely included anterior wall infarction (OR 1.36; 95% CI 1.32 to 1.40), Killip class 2 or 3 (OR 1.77; 95% CI 1.72 to 1.83), prior myocardial infarction (OR 1.33; 95% CI 1.30 to 1.37), prior history of congestive heart failure (OR 1.88; 95% CI 1.82 to 1.95), and diabetes mellitus (OR 1.34; 95% CI 1.30 to 1.38). Physicians are prescribing ACE inhibitors acutely in patients with AMI with increasing frequency. Patients with evidence of congestive heart failure and those with anterior myocardial infarction have the greatest expected benefit from such therapy, and these persons receive such treatment most often. However, most patients hospitalized with AMI do not receive this potentially life-saving therapy.

Aged↗
PubMed1995

Significance of a coronary artery with thrombolysis in myocardial infarction grade 2 flow "patency" (outcome in the thrombolysis and angioplasty in myocardial infarction trials). Thrombolysis and Angioplasty in Myocardial Infarction Study Group.

To determine whether pharmacologic reperfusion to Thrombolysis in Myocardial Infarction (TIMI) grade 2 flow during acute myocardial infarction confers the same clinical benefit as restoration of TIMI 3 flow, in-hospital clinical and angiographic outcomes in 1,229 patients prospectively enrolled in the Thrombolysis and Angioplasty in Myocardial Infarction trials were analyzed. Patients were treated with intravenous tissue plasminogen activator or urokinase, or both. Angiography of the infarct-related artery 90 minutes after initiation of thrombolytic therapy demonstrated TIMI grades 0, 1, 2, or 3 flow in 20%, 7%, 17%, and 55% of vessels, respectively. Rescue or adjunctive coronary angioplasty was performed in 80%, 27%, and 16% of patients with TIMI 0/1, 2, or 3 flow, respectively. Predischarge angiography was performed in 963 patients. A significant gradient of increasing mortality was seen in patients with lower TIMI flow (4.3%, 6.1%, and 10.1% with TIMI 3, 2, and 0/1 flow, respectively, p = 0.002). The incidence of congestive heart failure and recurrent ischemia was significantly higher in patients with TIMI 2 than with TIMI 3 perfusion (26% vs 19% for heart failure, p = 0.03; 23% vs 17% for recurrent ischemia, p = 0.05). Acute left ventricular ejection fraction and infarct zone regional wall motion were also significantly improved in patients with TIMI 3 than with TIMI 2 flow, with trends toward better improvement in global and regional function in the TIMI 3 group. These findings were not affected by the use of acute coronary angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Angioplasty, Balloon, Coronary↗